消化系统内科学课件：The Digestive Diseases.ppt

1、The Digestive Diseases同济医院消化内科 田德安Chapter I IntroductionSection I: Structural and Functional Charateristics of Digestive SystemSection II: Diagnostic Examination of Digestive DiseasesSection III: Prevention and Treatment of Digestive DiseasesSection IV: Progress and Prospect第一章 引言第一部分： 消化系统的结构和功能特点第

2、二部分： 消化系统疾病的诊断第三部分： 消化系统疾病的预防和治疗第四部分： 进展与展望 EsophagusLiverAbdominal aortaStomachGall bladderSpleenPancreasDuodenumColonSmall intestineRectumIleumAppendixUpperRespiratoryTract食管肝脏腹主动脉胃胆囊脾脏胰腺十二指肠结肠小肠直肠回肠阑尾上呼吸道 Gastrointestinal diseases Liver diseases10%Each person may suffer from digestive diseases mo

3、re or less during their life 胃肠道疾病 肝脏疾病10%每个人在其日常生活中或多或少会患消化系统疾病每个人在其日常生活中或多或少会患消化系统疾病the third place in death causes of malignancies the second in death causes of malignancies gastric carcinoma hepatic carcinoma Total 50%恶性肿瘤死亡原因中位居第三 恶性肿瘤死亡原因中位居第二胃癌肝癌总数 50%Processes of Digestive Function Ingestion

4、 Mechanical processing Digestion Secretion Absorption Excretion 消化功能 摄入 机械加工 消化 分泌 吸收 排泄 Section I: structural and function characteristics of digestive system第一部分：消化系统结构与功能特点 endocrine (内分泌) exocrine (外分泌) gastrointestinal motion nervous regulation humoral regulation blood circulation Lymph circula

5、tionIntimate cooperation 内分泌 外分泌 胃肠运动 神经调节 体液调节 血液循环 淋巴循环密切合作Oesophagus: Conduit between mouth and stomachStomach: Digestion of proteins; foodstuffs reduced to liquid form; storage; sterilisationPancreas: Digestive enzymes for digestion of fats, carbohydrates and proteinsLiver: Bile salts for digest

6、ion/absorption of fats in small intestine Gallbladder: Stores and concentrates bileSmall intestine: Final stages of chemical digestion and nutrient absorption Large intestine: Water absorption, bacterial fermentation and formation of faecesMouth: Foodstuffs broken down by chewing; saliva added as lu

7、bricant IngestionTransport Digestion/Secretion Absorption Excretion食管：口腔与胃之间的管道食管：口腔与胃之间的管道胃：消化蛋白质；将食物浓缩为液态；存储；灭菌胃：消化蛋白质；将食物浓缩为液态；存储；灭菌胰腺：用于消化脂肪，碳水化合物和蛋白质的消胰腺：用于消化脂肪，碳水化合物和蛋白质的消化酶化酶肝脏：小肠内消化肝脏：小肠内消化/吸收脂肪所需的胆盐吸收脂肪所需的胆盐 胆囊：储存和浓缩胆汁胆囊：储存和浓缩胆汁小肠：化学性消化的最后阶段及营养的吸收小肠：化学性消化的最后阶段及营养的吸收 大肠：水的吸收，细菌发酵及粪便的形成大肠：水的吸

8、收，细菌发酵及粪便的形成口腔：食物通过咀嚼分解；唾液作为润滑剂口腔：食物通过咀嚼分解；唾液作为润滑剂 摄入运输 消化/分泌 吸收 排泄rapid renewing rate: 72h1. Mucosa of the gastrointestinal tract 1. 胃肠道黏膜 快速更新率：72小时destruction of physiological function of mucosal layer Hemorrhageloss of massive liquidinvasion of pathogendisruption of digestive functionmalnutritio

9、n resulting from obstacle of absorption of nutritional materials.黏膜层生理功能的破坏出血出血大量的液体损失大量的液体损失病原体入侵病原体入侵消化系统功能失调营养物质吸收障碍导致的营养不良。营养物质吸收障碍导致的营养不良。2. Motivation of gastrointestinal tract Smooth muscle tissue found in almost every organ Pacesetter cells (电起搏细胞 ) Trigger waves of contraction Vital role in

10、 moving materials along tract Peristalsis segmentation2. 胃肠道动力学 平滑肌几乎存在于每一个器官 电起搏细胞 触发收缩波 在消化道输送食糜的过程中起重要作用 蠕动蠕动 分割分割 纵行肌 环形肌 收缩从口腔至肛门环形肌在食物团块后方收缩纵行肌在食物团块前方收缩收缩 收缩 环形肌层的收缩将食物团块向前推进蠕动 分割 Disorder of motivation abdominal pain Vomiting abdominal distension increased frequency of movement of bowel const

11、ipation 动力紊乱 腹痛 呕吐 腹胀 肠运动频率增加 便秘 Hormone of gastrointestinal tract:brain-gut peptide (脑肠肽)胃肠道激素：脑肠肽激素激素分泌分泌靶细胞靶细胞对动力的影响对动力的影响促释放的因素促释放的因素抑释放的因素抑释放的因素胃泌素胃内的G细胞壁细胞无腔内的多肽及氨基酸；胃泌素释放肽和神经反射释放的乙酰胆碱pH1.5；生长激素抑制素缩胆囊素小肠内分泌细胞；脑和肠神经元胆囊，胰腺，胃平滑肌细胞刺激胆囊收缩以促胆汁释放；抑制胃排空；促肠道运动脂肪酸及某些氨基酸生长激素抑制素胰泌素小肠内分泌细胞胰腺，胃抑制胃排空小肠内酸性物质生

12、长激素抑制素肠抑胃肽（GIP）小肠内分泌细胞胰内分泌腺中的细胞无小肠内的葡萄糖，脂肪酸，氨基酸胃动素小肠内分泌细胞胃、十二指肠的平滑肌刺激复合运动禁食；神经刺激引发的每1.5-2h的周期性释放Deep muscular plexusSubmucosalarteryMuscularis mucosaSubmucosalplexusMUCOSAMyenteric plexusLongitudinal muscleCircular muscleENS（enteric nervous system，肠之脑） 深肌丛深肌丛黏膜下动脉黏膜下动脉 黏膜肌层黏膜肌层黏膜下黏膜下神经丛神经丛 黏膜黏膜肌间神经丛

13、肌间神经丛 纵行肌纵行肌 环状肌环状肌ENS（肠神经系统，肠之脑） Mucosal Defence Mucosal Immune system Immunological function of gastrointestinal tract1. Lymphoid aggregate (集合淋巴结集合淋巴结)2. Intraepithelial lymphocytes (上皮内淋巴细胞上皮内淋巴细胞)3. Lymphocytes of lamina propria mucosae（黏膜固有层淋巴细胞（黏膜固有层淋巴细胞） 黏膜的防御黏膜的防御 黏膜免疫系统黏膜免疫系统 胃肠道免疫功能1. 集合淋

14、巴结集合淋巴结2. 上皮内淋巴细胞上皮内淋巴细胞3. 黏膜固有层淋巴细胞黏膜固有层淋巴细胞Their Relationship with auto-immune diseases Inflammation: Immune cell of gastrointestinal mucosa may attract inflammatory cells and activate them to lead to inflammation of gastrointestine. Auto-immune diseases: Immune system of gastrointestinal tract ma

15、y play a role in auto-immune diseases and immune resistance, for example, gliadin (麦胶蛋白) antigen-presented by epithelial cells of mucosa may activate auto-reactive T cells and lead to malabsorption at small intestine . 与自身免疫病的关系 炎症：炎症：胃肠道黏膜的免疫细胞可募集和激活炎症细胞进而引发胃肠道炎症。 自身免疫性疾病：自身免疫性疾病：胃肠道的免疫系统可能在自身免疫性疾病

16、和免疫抵抗中发挥一定作用，例如，由黏膜上皮细胞递呈的麦胶蛋白抗原可激活自身反应性T细胞并导致小肠的吸收障碍。Liver - structural characteristics Double blood supply portal vein: 75% bloodhepatic artery: 25% blood1500ml/minLiver cell plateSinusoidCentral vein肝脏 - 结构特征 双重血液供应双重血液供应门静脉：75% 血供肝动脉：25% 血供1500ml/min肝细胞板 血窦中央静脉小叶内胆管门管区肝门静脉分支胆管小叶间隔小叶组织 Liver acin

17、us 肝腺泡肝腺泡肝动脉分支肝门静脉分支肝小叶中央静脉小叶间隔肝血窦门管区（肝脏三联征）Intra-hepatic non-substantial cells: hepatic sinusoidal endothelial cell Kupffer cell Hepatic stellate cell Lymphocyte: Natural Killer Cell, T cell, B cell Dendritic cells肝内非实质细胞： 肝窦内皮细胞 枯否细胞 肝星状细胞 淋巴细胞：自然杀伤细胞，自然杀伤细胞，T细胞，细胞，B细胞细胞 树突状细胞 Section IIDiagnostic

18、 examination for digestive diseases第二部分消化系统疾病的诊断Diagnostic examination for digestive disease History and symptomsDysphagia(吞咽困难)NauseaVomitingEructation (嗳气)Sour regurgitation (反酸)Anorexia (食欲不振)Heartburn (烧心)Early full （早饱） Abdominal distension Abdominal pain Diarrhea （腹泻） Abdominal mass Constipati

19、on （便秘） Jaundice (黄疸) Hematemesis (呕血) Melaena (黑粪) Hemafecia (便血).消化系统疾病的诊断 病史和症状 吞咽困难吞咽困难 恶心恶心 呕吐呕吐 嗳气嗳气 反酸反酸 食欲不振食欲不振 烧心烧心 早饱早饱 腹胀腹胀 腹痛腹痛 腹泻腹泻 腹部肿块腹部肿块 便秘便秘 黄疸黄疸 呕血呕血 黑粪黑粪 便血便血Diagnostic examination for digestive disease Physical examination Hepatomegly (肝大) Hypersplenotrophy（脾大）ascitesspider tel

20、angiectasia (蜘蛛痣)liver palm (肝掌)facies hepatica (肝病面容)Jaundicesubcutaneous varicos vein of abdominal wall (腹壁静脉曲张) xanthoma (黄色瘤) 消化系统疾病的诊断消化系统疾病的诊断 体格检查 肝大肝大 脾大脾大 腹水腹水 蜘蛛痣蜘蛛痣 肝掌肝掌 肝病面容肝病面容 黄疸黄疸 腹壁静脉曲张腹壁静脉曲张 黄色瘤黄色瘤Laboratory and auxiliary examination- BloodGastrointestinal diseases:Rutine blood test

21、 and biochemical test are not specific for diagnosis of gastrointestinal diseases, but are useful for assessment of severity and activity of some diseasesLiver diseases: ALT AST ALP r-GT serum protein Albumin PT serum coagulation factor Blood tests are important for diagnosis and following up of liv

22、er diseases. Serum marker: hepatitis A、B、C、D and Eimmunological test: immunoglobuline, anti-mitochodrial antibody anti-nuclear antibody, (ANA) anti-smooth muscle (ASM)实验室及辅助检查 - 血消化道疾病：常规血液学检查和生化试验对诊断消化道疾病不具特异性，但对于评常规血液学检查和生化试验对诊断消化道疾病不具特异性，但对于评估某些疾病的严重和活动程度有一定帮助。估某些疾病的严重和活动程度有一定帮助。肝脏疾病： 谷丙转氨酶 (ALT)

23、 谷草转氨酶 (AST) 碱性磷酸酶 (ALP) r-谷氨酰转肽酶 (r-GT) 血清蛋白 白蛋白 凝血酶原时间 (PT) 凝血因子血液检查是肝脏疾病的诊断及其随访的重要检测指标。血液检查是肝脏疾病的诊断及其随访的重要检测指标。血清标志物：甲、乙、丙、丁、戊型肝炎免疫学试验： 免疫球蛋白 抗线粒体抗体 抗核抗体 (ANA) 抗平滑肌抗体 (ASMA)Laboratory and auxiliary examination-Stool and UrineFor gastrointestinal diseases, stool test is a simple and convenient but

24、 easily omitted onegastric juice excretion function testintestine aborption function testpancreas exocrine function testBC-or14C-urea expiration testBiopsypeeled cell examination routine test OB test parasites test Hp testUrine bilirubin and urobilinogen (尿胆原) are useful for diagnosis and differenti

25、ation of jaundice. Other laboratory tests molecular amplificationprobe hybridizationsequence analysisrestriction endonucleasegene chip Application of molecular biology 实验室及辅助检查 - 粪、尿胃肠疾病时，粪便检查是简单方便但极易被忽略的检查。胃液分泌功能试验小肠吸收功能试验胰腺外分泌功能试验BC-或14C-尿素呼气试验活检脱落细胞检查 常规试验 隐血试验 寄生虫试验 幽门螺杆菌检测尿胆红素和尿胆原是诊断及鉴别黄疸的有效指标。

26、其它实验室检查分子放大探针杂交序列分析限制性内切酶基因芯片分子生物学的应用Laboratory and auxiliary examination-Endoscopyultrasound endoscope Fiber endoscopeelection endoscope Capsule endoscope 实验室及辅助检查 - 内镜超声内窥镜纤维内窥镜电子内窥镜 胶囊内窥镜 Gastroscope Duodenoscope Intestinoscope colonoscope Abdominoscope Bile duct scope PancreaticoscopeAccording t

27、o demands for various anatomic sites:Laboratory and auxiliary examination-Endoscopy 胃镜胃镜 十二指肠镜十二指肠镜 小肠镜小肠镜 结肠镜结肠镜 腹腔镜腹腔镜 胆管镜胆管镜 胰管镜胰管镜根据不同的解剖部位的要求：实验室及辅助检查 - 内镜Laboratory and auxiliary examination-ERCPEndoscopic retrograde cholangiopancreatography, ERCP become an important strategy for diagnosis and

28、 treatment of pancreatic and biliary diseases. 实验室及辅助检查实验室及辅助检查 - ERCPERCP已成为诊断和治疗胰腺和胆道疾病的重要手段。Radiological Examination Ultrasound examination is a first selective non-traumatic examination, X-ray examination computer tomography（CT） magnetic resonance imaging（MRI）These are valuable not only for diag

29、nosis of occupying diseases of the liver, pancreas gallbladder such as cyst（囊肿）, abscess（脓肿）, tumor, stone but also for diagnosis disseminated disorders such as fat liver, liver cirrhosisi, pancreatitis.影像学检查 超声检查是首选的非创伤性检查 X射线检查 计算机断层扫描（CT） 磁共振成像（MRI）这些检查不仅有助于诊断肝脏，胰腺和胆囊的占位性病变，如囊肿，脓肿，肿瘤，结石等，同时也为脂肪肝，

30、肝硬化，胰腺炎等播散性疾病的诊断提供依据。Positron Emission Tomography（PET）PET may reflect physiological function and explain normal or abnormal function imaginally and quantitatively, and has been widely used for localization and grading of tumor.正电子发射断层扫描（PET）PET能反映机体的生理功能，对正常或异常的功能 做出形象化和量化的解释，目前已广泛用于肿瘤的定位和分级。Motivat

31、ive examination of digestive tract消化道的动力学检查Section IIIPrevention and Treatment of Digestive Diseases第三部分消化系统疾病的预防和治疗Prevention and Treatment of Digestive Diseases General therapy: Dietary Nutrition Psychiatrical therapy Drug Therapy Surgical therapy or Intervention Therapy including therapeutic endo

32、scope, TIPS, TACE and so on.消化系统疾病的预防和治疗 一般治疗： 膳食营养 精神疗法 药物治疗 手术治疗或介入治疗，包括 治疗性内镜，经颈静脉肝内门体分流术(TIPS)，经导管肝动脉化疗栓塞术(TACE)等。Section IVProgress and Prospect第四部分进展与展望Progress and Prospect Digestive fiber endoscope gave revolutionary changes to gastroenterology in 1960s. After continuous improvement, digesti

33、ve endoscope may access almost all the organs of digestive system, and widely used for diagnosis of stomach, intestine, gallbladder, pancreas. Recently, ultra sound endoscope, magnified endoscope, laser scanning endoscope, capsule endoscope continuously improved diagnosis of small and early lesions.

34、 With the vigorous development of therapeutic endoscope, many digestive diseases which resort to surgery in the past may be treated with less traumatic therapeutic endoscope.进展与展望 1960年代，消化道纤维内镜给胃肠病学带来了革命性的变年代，消化道纤维内镜给胃肠病学带来了革命性的变化。经过不断改进，消化内镜可以探查几乎所有的消化系化。经过不断改进，消化内镜可以探查几乎所有的消化系统器官，并广泛应用于诊断胃，肠道，胆囊和

35、胰腺疾病。统器官，并广泛应用于诊断胃，肠道，胆囊和胰腺疾病。 最近，超声内镜，放大内镜，激光扫描内镜，胶囊内镜在最近，超声内镜，放大内镜，激光扫描内镜，胶囊内镜在诊断微小及早期病变方便正不断完善。诊断微小及早期病变方便正不断完善。 随着治疗性内镜的蓬勃发展，许多在过去需要诉诸手术的随着治疗性内镜的蓬勃发展，许多在过去需要诉诸手术的消化系统疾病可采用创伤性更小的治疗性内镜进行治疗。消化系统疾病可采用创伤性更小的治疗性内镜进行治疗。Discovery and study of Helicobacter the incidence of Hp of peptic ulcer patient is m

36、uch higher than that of control common population successful eradication of H.pylori decrease the recurrence of ulcer 幽门螺杆菌的发现及研究 消化性溃疡患者的Hp发病率比正常人高很多 成功根除Hp能减少溃疡的复发 J. Robin WarrenMarshall and Warren discovered the Hp corporately in 1983 and were rewarded nobel prize in 2005.Barry MarshallWarren an

37、d MarshallJ. Robin WarrenMarshall和Warren于1983年共同发现幽门螺杆菌，并于2005年授予诺贝尔奖。Barry MarshallWarren and MarshallChange of profiling of digestive diseases in our countryPeptic ulcerGastric carcinoma Gastro-esophagus reflect disease (GERD)Acute and chronic pancreatitisInflammatory bowel disease (IBD) Functiona

38、l digestive diseaseAlcohol liver diseaseNon-alcohol fat liverMalignancies （colon cancer， pancreatic carcinoma）我国消化系统疾病谱的变化消化性溃疡胃癌胃食管反流性疾病 (GERD)急性和慢性胰腺炎炎症性肠病 (IBD) 功能性消化道疾病酒精性肝病肺酒精性脂肪肝恶性肿瘤（结肠癌，胰腺癌）Hot spots of study (diseases) Digestive carcinomas Precancerous diseases Liver fibrosis Liver function

39、failure Liver transplantation Early diagnosis研究热点 （疾病） 消化道肿瘤消化道肿瘤 癌前病变癌前病变 肝纤维化肝纤维化 肝功能衰竭肝功能衰竭 肝移植肝移植 早期诊断早期诊断SurgeryRadio-therapyChemo-therapyIntervention therapyImmunotherapy Gene therapyHot spots of study (Therapies)手术放疗化疗介入治疗免疫治疗 基因治疗研究热点 （治疗方法） Tumor markers Genomics and proteomics of tumor Stem cellsHot spots of study (basic research) 肿瘤标志物 肿瘤的基因组学和蛋白组学 干细胞研究热点 （基础研究）